Gastrointestinal

Acute Cholecystitis

Severe colicky right upper abdominal pain radiating to the right shoulder, with a positive Murphy's sign. Treat with an injectable NSAID and antispasmodic, then refer to a surgeon.

ICD-10: —
Source: OPD handbook pp.54–57
Status: Draft

Not yet reviewed by a clinician. Check doses and brands against current national guidelines before use.

Symptoms

Pain in the right upper abdomen
Severe, colicky, sudden in onset
Radiating to the right shoulder and tip of the scapula

Diagnosis

Differential diagnosis of right upper abdominal pain: gastritis, pancreatitis, cholangitis, acute hepatitis
Examine vitals
Abdominal examination: Murphy's sign positive
USG abdomen

Treatment

Step 1 of 3

1. Acute management (injectables)

Injectable NSAID
Injectable antispasmodic

Prescription

Ketorolac injectionNSAID injection

DoseIM stat

Brand Inj Toradol

Diclofenac sodiumNSAID

Doseless effective than ketorolac

Brand Inj Voren / Diclo

Also sold as Voren, Diclo, Dicloran

DrotaverineAntispasmodic

DoseIM stat

Brand Inj No-Spa

Also sold as No-Spa, Nospa, No-Spa Forte

Step 2 of 3

2. Discharge medicines

Antibiotics if an acute attack (prophylaxis for cholangitis) or the patient is febrile

Prescription

LevofloxacinFluoroquinolone antibiotic

Dose250 mg BD

Brand L-Cyn

Also sold as L-Cyn, Leflox, Efflox (spelling unclear in book), Levo

Cefixime3rd-generation cephalosporin

Dose400 mg OD

Brand Caricef

Also sold as Cefspan, Cefim, Caricef, Tixomer, Cefiget

Rising resistance in Salmonella Typhi; not reliable as a sole agent in XDR typhoid.

NimesulideNSAID

Doseas per NSAID table (100 mg 1+1)

Brand Tab Nims

Also sold as Nims, Nimusil

NaproxenNSAID

Dose500 mg BD

Brand Tab Neoprox

Also sold as Neoprox, Neopron, Flexin, Synflex

PhloroglucinolAntispasmodic

Dose1+1

Brand Tab Spasrid

DrotaverineAntispasmodic

Dose40 mg 1+1+1, or 80 mg 1+1

Brand Tab No-Spa 40 mg

Also sold as No-Spa, Nospa, No-Spa Forte

OmeprazoleProton pump inhibitor

Dose20 mg OD

Brand Cap Ruling

Also sold as Risek, Teph, Ruling, Ruling sachet, Omega

Step 3 of 3

3. Investigation and referral

USG abdomen
Refer to a surgeon for an opinion regarding cholecystectomy
Avoid oily things

Sample prescription from the book (patient details removed)

Female, 40 y, severe pain right upper abdomen radiating to the right shoulder, colicky, 1 hour; tender abdomen, Murphy's positive: Inj Toradol IM stat; Inj No-Spa IM stat; Tab L-Cyn 250 mg 1+1; Tab Nims 100 mg 1+1; Tab Spasrid 1+1; Cap Ruling 20 mg 1+0; avoid oily things; refer to surgeon; plan USG abdomen.